• Healthcare Business 101

Coding E/M Using MDM- Are You Doing It Right?

With changes in coding that happen annually and even quarterly, it is vital that providers understand how to make sure that their progress notes are compliant.

Each progress note is broken down into 4 sections- the diagnoses, the date reviewed and collected, the risk, and the measuring of the medical decision making, aka MDM.

1st Section:

The progress note must contain a complete evaluation- Hx, exam, Dx measures, and Tx. With that information should the provider choose the level of which to bill.

2nd Section:

The encounter with the patient should also include the data to which the provider may have ordered, reviewed, interpreted, or analyzed. All of this information counts. Additionally, any discussion with other professionals, facilities, and even non-healthcare professionals are also counted, including receiving additional history from an independent historian, such as a guardian, social worker, or family member, in cases where the patient cannot provide their own complete history.

3rd Section:

RISK- What is the morbidity risk for the patient? For the purpose of medical decision making, the measure is weighted on the consequences of the problems being addressed during the visit if being treated accordingly. There are 3 risk levels: low, moderate, and high.

4th Section:

The final section is ensuring that the documentation in the progress note meets or exceeds 2 of the 3 elements of the level of MDM.

Melanie Puccella, President


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